VA patient load outpaced budget

Floyd Smith, 53, a homeless Army veteran, seeks assistance on Thursday at American Legion Post 1 in Phoenix. The post has been hosting a “crisis center” to help veterans sign up for medical appointments, process claims and address any other needs.(Photo: Rob Schumacher/The Republic)

Story Highlights

VA program expansion and an aging vet population have contributed to the backlog of patients.

Growth in the VA budget has not kept pace with growth in the patient population.

The scandal enveloping the Department of Veterans Affairs was years in the making, as patient-eligibility guidelines expanded without corresponding funding, swamping health centers with sick veterans whom dishonest bureaucrats chose to ignore rather than treat.

Federal reports and interviews suggest that VA administrators falsified wait-time lists because the agency's rolls had swollen and its administrators were under constant pressure to bring wait times down — in fact, their bonuses were contingent on it.

• The VA, under the direction of Congress, expanded the scope of services it provides.

• World War II, Korea and Vietnam-era veterans need more care as they move into and through retirement years.

• Iraq and Afghanistan-era veterans use VA services far more than previous generations of vets.

• Veterans of all eras more recently have depended on VA benefits to counter recession-related losses of private-sector health-care benefits.

The VA operates 150 hospitals and 820 outpatient clinics nationwide. The most recent figures show the system provided nearly 80 million outpatient medical appointments to veterans in 2011, according to a report by the Government Accountability Office.

The system is built to accommodate many more veterans than just those who have war-related ailments, said Chandler resident Dennis W. Snook, a retired analyst for the Congressional Research Service.

"There is a tendency to think ... the increase is because of fighting these wars in the Middle East. That's not the reason at all," said Snook, who served for a decade as the service's principal analyst for issues concerning veterans.

The logjam primarily has been caused by aging veterans seeking care for an ever-broadening range of conditions that are not related to military service, he said.

More services

Congress began loosening requirements for vets seeking VA medical service after the Spanish-American War in 1898. Congress relaxed the requirements again and again after subsequent wars. Meanwhile, advances in medicine allowed people to live longer.

As a result, Congress and the VA created an upward patient spiral, Snook said. The VA treated more conditions, which required more facilities. And with more facilities, the VA began treating more conditions.

But funding for the VA fell behind, said U.S. Rep. Ann Kirkpatrick, D-Ariz., a member of the House Veterans' Affairs Committee.

In 1996, Congress passed the Veterans Health Care Reform Act, which expanded eligibility for VA care to all veterans. Enrollment in VA health-care facilities increased from 2.9 million in 1996 to 7 million in 2003, a 141 percent increase.Yet funding for the VA increased by less than 60 percent during that time.

"That is sort of the genesis of the problem that we're seeing right now," Kirkpatrick said. "It's important to keep that in mind — that we're just seeing the convergence of increased usage and lack of funding."

As veterans waited ever longer for eligibility determinations and medical appointments, orders went out to increase efficiency and to reduce wait times. The bureaucratic response was to falsify the numbers.

"This isn't that big a surprise to me, because government by its nature is not very accountable or meritocratic," said California management consultant Patrick Lencioni, author of "The Advantage: Why Organizational Health Trumps Everything Else in Business."

"It seems like they have very little incentive or motivation for getting better as long as they're avoiding scandal."

Lack of trust

U.S. Rep. Jeff Miller, R-Fla., chairman of the House Veterans' Affairs Committee for 3½ years, said the VA's culture of dishonesty runs deep.

Miller said he has visited 40 VA and Department of Defense facilities since the start of the 113th Congress in January 2013.

"I have been to medical centers across this country where directors have lied to me while I have sat at their conference table and they have told me they have no wait times," he said.

Even the VA's own Office of Inspector General called out the agency, noting that its investigation in the wake of the recent wait-time scandal found rampant gaming of the appointment-tracking system dating back years.

"The overarching environment and culture which allowed this state of practice to take root must be confronted head-on if VA is to evolve to be more capable of adjusting systems, leadership and resources to meet the needs of veterans and families," the report stated.

Who's to blame? President Barack Obama's VA secretary, Eric Shinseki, took the fall, resigning the same day last month that the inspector general'sinterim report was released — and after more than 100 members of Congress had called on him to step down.

Lencioni said failures noted by the inspector general indicate a lack of honesty, courage and accountability at the agency's top levels.

"Where did the breakdown occur? If it was ... Shinseki's people that knew and didn't tellhim, then you know who I blame? Him. Because you have to create an environment of trust on a team," Lencioni said.

Shinseki failed to create an environment in which employees felt empowered to tell him that fraud was being committed, said Randy Pennington, president of Pennington Performance Group of Addison, Texas.

"The hardest thing for a CEO to do is to get that unfiltered information. You have to continually go out and foster people talking to you, and you have to then make sure that people aren't punished for bad news," Pennington said.

Need for help on rise

Administrators no doubt had their work cut out for them in trying to reduce wait times and move more veterans through the system on budgets that weren't keeping pace.

The number of veterans with service-related medical conditions — defined as ailments caused or aggravated by injuries and disease during active military service — has been on the rise, particularly among post-9/11 veterans, according to the VA.

While the demand for medical service is surging, the actual number of veterans is on a steady decline as former military personnel die of natural causes, according to the VA.

The U.S. veteran population stood at nearly 29 million in 1985. It nowis at 22 million, according to the VA. That number is projected to fall to 19.6 million by 2020; 16.8 million by 2030; and 14.5 million by 2040.

About 40 percent of the current veteran population is enrolled in the VA health-care system.

While the numbers of World War II, Korea and Vietnam vets diminish during the coming years, the number of post-9/11, Iraq and Afghanistan vets is expected to climb as active-duty troops conclude their military careers.

Each group of veterans has unique medical needs, according to VA officials and veterans' advocates.

Korea and Vietnam vets' needs are complicated, said Rick Weidman, executive director for policy and government affairs for the Washington-based Vietnam Veterans of America.

They're increasingly susceptible to typical age-related ailments. Those who served in the Vietnam War between 1961 and 1975 when they were 18 years old are now between 57 and 71 years old.

About 44 percent of the overall veteran population is 65 or older. In addition, many Korea and Vietnam vets have what Weidman calls "toxic wounds," which are ailments that surface decades after their causes.

Those include exposure to Agent Orange, an herbicide that was sprayed by the planeload on Southeast Asia's dense jungles, and the emerging effects of post-traumatic stress disorder, an anxiety condition commonly known as PTSD.

Korea and Vietnam-era vets largely went undiagnosed and untreated for PTSD, which decades ago was called shell shock, battle fatigue and stress-response syndrome. Most Korea and Vietnam vets with PTSD dealt with it by suppressing it, Weidman said.

The VA health-care system also was unprepared for the influx of veterans from the Iraq and Afghanistan wars, he said. The wars have lasted years longer than Washington decision-makers initially anticipated. Advances in battlefield medical treatment have helped troops survive wounds that were lethal in previous wars.

The VA system particularly was ill-equipped to deal with waves of young vets with PTSD, traumatic brain injuries, amputations and burns caused by improvised explosive devices and other weapons, according to Weidman and others.

Those types of conditions are difficult and expensive to treat, Kirkpatrick noted.

"We're seeing more of that than in any other veteran population," she said.

The VA also was unprepared for the influx of women service members returning from Iraq and Afghanistan, Kirkpatrick said.

The VA needs more women's clinics and women's wards within hospitals to accommodate the fastest-growing segment of the veteran population.

The bottom line

Older vets are competing with younger vets for medical services from a limited pool of providers.

Roughly 16 percent of all veterans use the VA as their primary source for health care, according to a 2010 VA survey of vets. The number jumps to nearly 19 percent among Vietnam veterans and about 29 percent among post-9/11 veterans.

Similarly, nearly 12 percent of veterans use the VA in addition to other health-care providers for some services, according to the survey. The figure is substantially higher among veterans of recent wars.

"There has been a failure on the part of the VA going back to the beginning of the Iraq and Afghanistan conflicts to anticipate increases in need for primary and specialty care," Kirkpatrick said. "These are not issues that have arisen in the past year or two."

There's no reasonable explanation why the VA didn't account for the surge of post-9/11 vets, said Daniel M. Dellinger, national commander of the American Legion.

The investigations and congressional hearings into the VA need to be completed soon so that changes can be made to the agency's culture and practices, Dellinger said.

"The real question is how many veterans have to die waiting for all of that? It needs to be done now," he said.

Who gets VA medical care

A person who served in the active military service and who was discharged or released under conditions other than dishonorable is a veteran eligible for health-care benefits. The amount, degree and types of care vary based on a priority system. There are eight levels of veterans in the system, as explained at www.va.gov/healthbenefits/resources/priority_ groups.asp. They break down as follows:

• Priority Group 1: Veterans with service-connected disabilities that are rated 50 percent or more. Veterans assigned a total disability rating for compensation based on unemployability.

• Priority Group 2: Veterans with VA service-connected disabilitiesthat are rated at 30 or 40 percent.

• Priority Group 3: Veterans who are former POWs. Also those awarded the Purple Heart or Medal of Honor; those discharged due to a disability incurred or aggravated in the line of duty; and those with service-connected disabilities that are rated at 10 or 20 percent.

• Priority Group 4: Veterans receiving increased compensation or pension based on their need for regular aid and attendance or by reason of being permanently housebound. Veterans determined by the VA to be catastrophically disabled.

• Priority Group 5: Non-service-connected veterans and non-compensable service-connected veteranswho are rated at 0 percent, whose annual income and/or net worth are not greater than the VA financial thresholds. Also veterans receiving VA pension benefits or eligible for Medicaid benefits.

• Priority Group 6: Compensable 0 percent service-connected veterans. Veterans exposed to ionizing radiation during atmospheric testing or during the occupation of Hiroshima and Nagasaki; Project 112/SHAD participants; veterans who served in the Republic of Vietnam between Jan. 9, 1962, and May 7, 1975; veterans who served in the Southwest Asia theater of operations from Aug. 2, 1990, through Nov. 11, 1998; and certain other veterans who served in a theater of combat operations after Nov. 11, 1998.

• Priority Group 7: Veterans with incomes below the geographic means test income thresholds and who agree to pay the applicable co-payment.

• Priority Group 8: Veterans with gross household incomes above the VA national income threshold and the geographically adjusted income threshold for their resident location and who agree to pay co-pays. There also are subpriorities within Group 8.